PE Center of Excellence Accreditation Sign-Up

Overview:

Please fill out the form to begin the PE CoE Application.

Please note that each site must pay a nonrefundable application fee and sign The Consortium's NDA, BAA, and SoW before accessing the application portal.

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* 1. Name of Institution:

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* 2. Name of Healthcare System (if applicable):

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* 3. Institution City and State:

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* 4. Outside of the United States:

State/Region/County/ Territory/Province:

Country:

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* 5. What type of PE CoE will your institution be applying for (criteria linked here)

Comprehensive Care PE Center of Excellence

Regional Care PE Center of Excellence

Uncertain

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* 6. Institution's PERT Team Leader Contact Information:

Name:

Title:

Specialty:

Email Address:

Phone Number:

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* 7. Institution's Finance Contact Information (for invoicing and payment purposes):

Name:

Title:

Email:

Phone Number:

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* 8. Form of payment for the nonrefundable application fee:

Check

ACH

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* 9. Who should the legal documents be sent to for review and signature?

Contact Name:

Contact Email:

Contact Number:

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* 10. If applicable, please fill out other institutional members that will be involved with the application process:

Contact 1 Name:

Contact 1 Email:

Contact 2 Name:

Contact 2 Email:

Contact 3 Name:

Contact 3 Email: